What type of imaging is indicated for a patient presenting with left lower quadrant abdominal pain, possibly related to weightlifting (resistance training)?

From the Guidelines

For a patient with left lower abdominal dull ache who has been lifting weights, I would recommend starting with a CT scan of the abdomen and pelvis with IV contrast, as it is the most accurate and useful examination for left lower quadrant pain, guiding appropriate management and detecting subtle abnormalities 1. This approach is supported by the most recent evidence, which suggests that CT is sensitive for small quantities of extraluminal intraperitoneal or retroperitoneal air, a critical finding indicating luminal perforation and often having surgical implications 1. The use of IV contrast material at CT can improve the characterization and detection of bowel wall pathology, pericolic abnormalities, vascular pathology, and intraabdominal fluid collections, making it a crucial component of the initial imaging evaluation 1. While ultrasound may be useful in some cases, such as evaluating soft tissue structures or suspected hernias, the patient's symptoms and history of weightlifting do not necessarily suggest a condition that would be better evaluated with ultrasound initially. Instead, the comprehensive evaluation provided by CT with IV contrast is likely to be more beneficial in guiding management and detecting potential complications, such as diverticulitis or bowel obstruction, which could be causing the patient's symptoms 1. Before proceeding with imaging, a thorough physical examination should be performed to help guide the imaging approach and identify any potential areas of concern. Key considerations in the imaging evaluation include:

• The patient's history of weightlifting, which may suggest a muscle strain or hernia
• The possibility of diverticulitis or other inflammatory conditions, which may require more comprehensive evaluation with CT
• The importance of detecting subtle abnormalities, such as extraluminal air, which may indicate a more serious condition requiring prompt intervention.

From the Research

Imaging Options for Left Lower Abdominal Dull Ache

The patient's complaint of a left lower abdominal dull ache, particularly after lifting weights, suggests the need for imaging to rule out various potential causes. Considering the location of the pain and the patient's activity, possible diagnoses could include diverticulitis, nephrolithiasis, or even a Spigelian hernia.

Recommended Imaging Tests

• Computed Tomography (CT) Scan: A CT scan with intravenous contrast media is often chosen for generalized abdominal pain, left upper quadrant pain, and lower abdominal pain 2. It can help diagnose conditions such as diverticulitis, nephrolithiasis, and hernias, including Spigelian hernias 3, 4.
• Ultrasonography (US): US can be useful, especially for right upper quadrant pain and for patients who have female reproductive organs to consider diagnoses like ectopic pregnancy or adnexal torsion 2. However, for left lower abdominal pain, CT might be more appropriate due to its ability to provide detailed images of the abdominal and pelvic structures.

Considerations for Imaging

• The choice of imaging study depends on the clinical suspicion of specific etiologies and the patient's symptoms 2.
• For patients with a history of lifting weights and presenting with left lower abdominal pain, a CT scan might be more informative to evaluate for hernias or other abdominal pathologies 3.
• Ultrasonography can be a first-line imaging modality for certain conditions but might not provide the comprehensive view needed for complex abdominal pathologies like Spigelian hernias or diverticulitis 3, 4.

Specific Conditions to Consider

• Diverticulitis: Can be diagnosed with CT scans, which show edematous thickening of the bowel wall and inflammatory changes within the adjacent mesenteric fat 4.
• Spigelian Hernia: Although less common, can mimic symptoms of diverticulitis and can be diagnosed with CT scans or ultrasonography, showing the defect in the abdominal wall, the hernial sac, and its contents 3.
• Nephrolithiasis: Can be evaluated with non-contrast CT scans, which are highly sensitive for detecting renal stones 5.